12 November 2009

Anonymous (or another reader of the same name) asked me: "Why would a bad hiring position be very hard to undo? Is it because due to the all the investment you have placed on this new employee? Or it also looks bad on your part if you had to fire them?"

Great question -- These are fun to run through, not because they're terribly tricky questions, but because it's useful to really formalize your thinking process.

The first downside of a bad hiring decision is of course the direct costs. You didn't know it was a bad hiring decision when you made it, and you can make an argument that it isn't a bad decision until or unless you have problems. Those problems, whatever they happen to be, will pose direct costs to your practice. Whether it's pissed off nurses due to jerky behavior or pissed off patients due to poor department flow management, there's a cost there. Worse, if it's a real bad decision, there are human costs from bad care and quite possibly direct legal costs from liability. You can get rid of a problem physician, and get through the rough patch, but it takes a while to recover your credibility as a leader that you are able to select the right candidates for your department, and it takes a while for your nursing staff/medical staff/administration to get over the negative impressions of your group that were fostered by the problem doc.

Then you have the opportunity costs You pick a bad apple and they make trouble. Chances are, you could have had someone better. Unless you are in a noncompetitive practice environment where you need to pay recruiters to bring you docs, you should be considering multiple candidates for each position. When you pick someone who turns out to be a liability, you could have had someone who was an asset instead. You never get a chance to recoup that lost time.

Then there's the simple fact that it's not easy to fire a doctor. Good practice requires that you have standards and procedures you follow before termination. Barring an egregious matter, you generally need to make multiple efforts to meet with (and document) discussions with the doc to let him or her know there are concerns, give clear examples of the concerns, and give them an opportunity to improve. Then you need to document their response to the intervention. This is good practice because in most cases it eliminates the need to consider a termination, but also because if you do progress to that step, a well-documented remediation process provides great legal protection against any allegations of improper firing.

Then, as a matter of process: we have a democratic group and I don't possess autocratic power to fire people at a whim. I would have to go to our HR committee multiple times and make a case for the necessity of the action. We're a soft-hearted bunch and it can be hard to convince our partners that there is no other good option. And when a doc is let go, it has a pretty significant negative effect on the morale of the group (especially if that doc's problems had been kept private prior to dismissal).

And finally, doctors are very litigious when their careers are threatened. They have the resources and a strong motivation to seek legal counsel and fight a termination. That can get expensive. Unless it's iron-clad termination for cause, you can either wind up paying to buy a doc out of his or her contract, or you can lawyer up and slug it out. Unless you have really carefully created a paper trail establishing the reasons for the firing, and scrupulously abided by the terms of the employment contract, an involuntary termination carries significant legal risk. Sometimes you can convince a doc to resign quietly in the interest of preserving their career -- a termination is a black mark on future credentialling checks. But again, there's a big risk if they choose to lawyer up instead.

Then finally, I just hate it. It's a miserable thing to have to fire someone. It's a very personal assault on their whole being, the profession they have dedicated their adult life to, and it makes me feel sick. It's even worse if it was someone I hired, because it feels like a personal failure on my part. To have someone move out here, relocate their family, and then have to fire them is awful. Fortunately, this is not something I have had to do much, but I dread it extremely. Which isn't to say that I shy away from it, when necessary, but I loathe the need and work very hard to obviate it.

So this is why I'm willing to spend so much time on my recruiting decisions. Getting the best people is the key to a successful and prosperous physician group, but getting the wrong person causes hours and hours of headache and heartache.

6 comments:

Or you can be like my hospital's administration and say, "Well, you can't change a doctor's behavior, so the nurses are just going to have to learn to live with it." Follow that up with disciplinary meetings for asking for pressors on a hypotensive patient when "you know that he doesn't like it when nurses tell him what to do."

It is interesting that the legal/litigation type reasons cited are essentially the same as in the defensive medicine, over-testing (every possibile outcome is equally probable mindset - to avoid possible problems in litigation) debate.

Just as defensive medical practice exists and is very costly to society, so does defensive hiring and defensive interviewing. It has permeated our culture without our realization of how it is impacting our behavior and associated the costly actions as a consequence.

But there's also a huge human cost to firings based on a minor error, racial or other discrimination, and so forth. That human cost has been huge, so making sure that people aren't fired because someone with power is being a jerk is important.

and nowhere in the world is this "huge human cost" fought for as intensely as it is here. usa has 70% of the world's lawyers.

as for the average docs, they can find work in average hospitals. for the forseeable future there will be more jobs than there are doctors, so unless you royally screw up, the job security will always be there.

I'm a long time reader (first time commenter) and am currently in medical school with an interest in emergency. This series on employment practices has been very entertaining and informative. Thank you.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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